A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse prepare the child for next?

Choice A reason: "Many infants outgrow the need for a shunt after the neonatal period." is not a correct response that the nurse should provide. This statement is false, as most infants with hydrocephalus will need a shunt for life. Only a small percentage of infants with post-hemorrhagic hydrocephalus may outgrow the need for a shunt .

Choice B reason: "The shunt will be replaced as your child grows to reduce pressure in the brain." is the correct response that the nurse should provide. This statement is true, as the shunt will need to be adjusted or replaced as the child grows to accommodate the changes in the size and shape of the head and the amount of fluid drainage. The nurse should educate the mother about the signs and symptoms of shunt malfunction and the need for regular follow-up visits.

Choice C reason: "Other pathways in the brain will drain fluid after the shunt is removed." is not a correct response that the nurse should provide. This statement is false, as the shunt is not removed unless there is a serious complication or the child no longer needs it. The shunt is a permanent device that bypasses the blocked or impaired pathways in the brain and allows the fluid to drain into the abdomen. Without the shunt, the fluid will accumulate in the brain and cause increased pressure and damage.

Choice D reason: "The shunt will have to be reinserted only if an infection or blockage develops." is not a correct response that the nurse should provide. This statement is false, as the shunt is not removed and reinserted unless there is a serious complication or the child no longer needs it. The shunt is a permanent device that stays in place unless it malfunctions or becomes infected. The nurse should educate the mother about the signs and symptoms of shunt infection and the need for prompt treatment.

Choice A reason: Instructing the mother to feed the infant nothing for 30 minutes after giving the iron drops is not a correct intervention. It may cause the infant to become hungry, fussy, or dehydrated. It may also interfere with the absorption of iron, as food can enhance the bioavailability of iron in the body.

Choice B reason: Suggesting placing the iron drops in the orange juice and then feeding the infant is not a correct intervention. It may alter the taste and color of the orange juice, making it less palatable for the infant. It may also reduce the potency of the iron drops, as iron can react with the citric acid and vitamin C in the orange juice and form insoluble complexes.

Choice C reason: Telling the mother to follow the iron drops with infant formula instead of orange juice is not a correct intervention. It may decrease the absorption of iron, as calcium and casein in the infant formula can bind with iron and form insoluble complexes. It may also increase the risk of gastrointestinal side effects, such as constipation, nausea, or vomiting.

Choice D reason: Giving the mother positive feedback about the way she administered the medication is a correct intervention. It reinforces the mother's behavior and encourages her to continue giving the iron drops as prescribed. It also acknowledges the mother's efforts and shows respect and appreciation. Following the iron drops with orange juice is a good practice, as vitamin C in the orange juice can enhance the absorption of iron in the body.